Prior Authorizations Play Crucial Role in Ensuring Appropriate Medication Use

By Susan A. Cantrell, RPh, CAE

As managed care professionals, we recognize that prior authorization (PA) is a crucial but often misunderstood utilization management tool. The bad rap that PAs have received recently, I believe, comes from misinformation about the process and challenges within in specific systems that can be corrected.

This includes examples in Dr. William E. Bennett Jr.’s Oct. 22 opinion piece in the Washington Post, where he alleges PA “exists so that many patients will fail to get the medications they need.”

We know this is certainly not the intent of a well-designed PA program for pharmaceuticals. PAs are not designed as a strategy to save money at the expense of patient care. Rather, we know that PAs help improve patient outcomes by encouraging the use of appropriate therapies with established evidence of efficacy and safety, and that provide the best value.

With PA so often misunderstood, perhaps we need to do a better job of explaining this tool to the general public. For example, we might provide an example of how PAs are applied to opioids as additional safeguards to ensure their appropriate use. Or how a PA might be applied to botulinum toxin to ensure the prescription is for medical, rather than cosmetic, purposes.

As managed care pharmacy professionals, we strongly believe in the value of PAs as a utilization management tool, and have streamlined the process, including by supporting standards-based, electronic-PA transactions.

But we also are continually looking for ways to improve the process. AMCP’s Professional Practice Committee recently developed nine specific concepts for effective PA practices, that include a focus on patient safety and appropriate medication use, and clinical decision making. We strongly support these concepts to allow for further collaboration between prescribers and payers to ensure that patients receive appropriate and timely access to drugs, devices, and other therapeutic agents. 

In the vein of developing best practices, we caution state lawmakers in their efforts to streamline the PA process by mandating the use of standardized PA forms. Our experience has found that these legislated efforts actually result in more cumbersome PA processes and outcomes.

The bottom line is AMCP wants to ensure that PAs are transparent and collaborative. Patients deserve timely, efficient access to appropriate therapies. This is our commitment with PAs.

Susan A. Cantrell is CEO of AMCP, a professional association that represents 8,000 managed care pharmacy professionals who design and implement pharmacy benefits for nearly 300 million Americans.